MentalHealth_DavidCarterPart1_DA.docx - Mental Health Case:...

Mental Health Case: David Carter, Part 1
Documentation Assignments
1. Document findings associated with your screening of Mr. Carter using the AIMS scale.
2. Document Mr. Carter’s performance of activities of daily living and his intake and output for the
day.
3. Reconcile Mr. Carter’s medications prior to hospitalization. 4. Identify and document key nursing diagnoses for Mr. Carter.
5. Referring to your feedback log, document all nursing care provided and Mr. Carter’s response to
this care.
0:06 You introduced yourself.
0:30 You washed your hands.
0:36 You identified the patient.
0:52 You asked if the patient had any known allergies.
1:18 You performed medication reconciliation.
1:38 You assessed the respiration.
1:51 You checked the pulse oximetry.
2:07 You measured the blood pressure.
2:23 You measured the temperature.
2:52 You auscultated the lung sounds.
From vSim for Nursing | Mental Health. © Wolters Kluwer.

3:06 You auscultated the heart sounds.
3:21 You checked the patient's skin.
3:41 You observed the appearance.
4:05 You assessed the attention.
4:14 You observed the motor activity.
4:28 You assessed the speech.
4:39 You assessed the thought processes.
4:55 You asked the patient: What is your full name? The patient said: My name
is David Carter.
5:03 You asked the patient: Have you taken your medication?
5:15 The patient said: I'm not going to eat; no one can make me eat
poison.\nYou answered: Have you had similar experiences? \nYou used
the therapeutic technique of encouraging comparison.
5:19 You asked the patient: Can you tell me a little bit more about what's
going on with you today? It was appropriate to ask the patient what was
going on with him to get an understanding of this.
5:39 The patient said: They came and got me and forced me into this poison
prison. It's your fault for keeping us here to rot of poison!\nYou answered:
My purpose for being here today is to help you and complete your
nursing assessment. \nYou used the therapeutic technique of giving
information.